LID SURGERY

When it comes to performing  surgery on or around the  eyelid, at what point should  a subspecialist be brought in,  or can a general ophthalmologist do it all?  These were among the questions debated at  the annual Walter Wright Ophthalmology  conference in Toronto, Canada.

'There is no question generalists can, and  should perform eyelid surgery,' said Patricia  Teal MD. She is an ophthalmologist and chief  of surgery at the Douglas Memorial Hospital  in Fort Erie. She also founded the Patricia  Teal MD Cosmetic Laser & Aesthetic Centre  in Fort Erie, Ontario.  Ryan Eidsness MD, added that he  considers all eyelid surgeries as cosmetic  procedures because “all patients expect good  aesthetic results.†He is an ophthalmologist  who practices at Focus Eyecare Specialists  in Regina Saskatchewan and is trained in  oculoplastics.

However, certain complex procedures  should be left to people who have additional  training specifically in either oculoplastic  or cosmetic surgery. These include lacrimal  repairs, reconstructive surgery/cancer-related  issues, orbit repairs and surgery specifically  for more complex cosmetic purposes. Both  debaters agreed with this. “When it comes to eyelid surgery, you  should do just what you’re comfortable  doing,†Dr Eidsness said. Generalists should  be able to perform common procedures like  lid laceration repair, ectropion, entropion  and blepharoplasty. These are within the  capabilities of all graduating residents, he said.

“It’s when you get into the larger  procedures and the less reproducible  procedures like ptosis repair, reconstruction  and canalicular repair - these should be left  for surgeons with subspecialty training,â€Â  he said.  Most generalists shy away from these  anyway. Generally, the reoperation rate for  ptosis is between three per cent to 20 per cent,  noticeably higher than for blepharoplasty,  ectropion and entropion surgeries, he noted.

Successful eyelid surgery means knowing  the anatomy. To start with one needs to know  where the eyelid is supposed to sit. “It’s surprising how many people don’t  know where it should sit. If you don’t know  this, and if you don’t understand the gender  and racial differences, you’re not going to get  a good result,†Dr Eidsness said. 

Another tip for successful eyelid surgery is  to understand surgical planes, with the goal to  restore normal anatomy, he added.  Sometimes blepharoplasty cases come  in with additional issues, which make the  surgery less straightforward and these should  be done by someone with more experience.  For instance, ptosis, or a drooping eyelid, can  have a number of different causes which may  require different approaches. 

“In patients where surgery is the  appropriate choice, you have to know your  options. For ptosis surgery, the anterior  approach is probably the most common,  though there are some good posterior  approaches. All of them can provide excellent  results, it’s knowing when to use them and  how to use them,†Dr Eidsness said.  

Cosmetic surgery

Ophthalmologists  wanting to perform more detailed cosmetic  surgery of the eye should undergo additional  training, Dr Teal said. “Cosmetic surgery is  really a subtype of oculoplasty. It’s goal is to  enhance the appearance of the eye toward  an aesthetic ideal, or restoring normal  appearance,†she said.

Not everyone is cut out to do cosmetic  surgery and there are requirements beyond  technical skill. “Do you have the right  personality and talents? Plus, are you the type  of person who likes to sit and talk to people?  You need to understand people’s lives, what  they want and why they want a cosmetic  procedure,†she explained.

Traits such as creativity and ingenuity are  not as straightforward. Cosmetic surgeons  need artistic vision and skill, along with some  artistic talent. “You have to appreciate and  understand what's beautiful. If you don’t, you  won’t have any success in the cosmetic field,â€Â  Dr Teal said.

Being mentored is important too, but it  can be tricky finding a good mentor, in part  because cosmetic surgery is competitive.  Running a cosmetic surgery office is  quite different from that of a general  ophthalmology practice. This is largely due  to the fact that cosmetic patients are healthy  patients, and need to be treated differently by  office staff. Don’t have well patients and sick  patients in the same waiting room, she said.